﻿#parse("partials/headerpopup.html")
<div class="mws-form">
    <form method="post" action="" id="formID">
    <div class="mws-form-cols clearfix">
        <div class="mws-form-col-4-8 alpha">
            <label>
                From</label>
            <div class="mws-form-item large">
                <input id="txtFrom" value="$DoctorName" type="text" class="mws-textinput" readonly="true" />
            </div>
        </div>
        <div class="mws-form-col-4-8 omega">
            <label>
                Specialist</label>
            <div class="mws-form-item large">
                <input id="txtSpecialist" value="$Specialist" type="text" class="mws-textinput" readonly="true" />
            </div>
        </div>
        <div class="mws-form-col-5-8 alpha">
            <label>
                Hospital Unit</label>
            <div class="mws-form-item large">
                <input id="txtHu" value="$HuName" type="text" class="mws-textinput" readonly="true" />
            </div>
        </div>
        <div class="mws-form-col-3-8 omega">
        </div>
        <div class="mws-form-col-8-8 omega">
            <label>
                Subject</label>
            <div class="mws-form-item large">
                <input id="txtSubject" value="$Subject" type="text" class="mws-textinput" readonly="true" />
            </div>
        </div>
        <div class="mws-form-col-8-8 omega">
            <label>
                Question</label>
            <div class="mws-form-item large">
                <textarea name="txtQuestion" rows="100%" cols="100%" readonly="readonly">Lorem ipsum dolor sit amet, consectetur adipiscing elit. Quisque non leo convallis nibh tristique commodo. Cras tincidunt hendrerit pharetra. Etiam erat magna, egestas sed placerat at, congue sed nisi. Nullam eget varius leo. Integer at justo a velit imperdiet pulvinar. Sed magna mi, sodales sit amet aliquet ac, eleifend eget sem. Nam ipsum lectus, fringilla sed rutrum ac, tempus in orci. Pellentesque condimentum dui a elit rutrum at posuere tellus dignissim. Aliquam erat volutpat.
                        </textarea>
            </div>
        </div>
        <div class="mws-form-col-8-8 omega">
            <label>
                Answer</label>
            <div class="mws-form-item large">
                <textarea name="txtAnswer" rows="100%" cols="100%" readonly="readonly"></textarea>
            </div>
        </div>
        <div class="mws-form-col-5-8 alpha">
            <label>
                Fee</label>
            <div class="mws-form-item large">
                <input id="txtFee" type="text" class="mws-textinput" />
            </div>
        </div>
        <div class="mws-form-col-3-8 omega">
        </div>
    </div>
    <div class="mws-button-row" style="position: relative; bottom: -6px;">
        <input name="buttonAction" id="buttonAction" type="submit" value="Reply" class="mws-button red" />
    </div>
    </form>
</div>
#parse("partials/headerpopup.html") 